Pushing the Boundaries of Living Donation Through Kidney Paired Donation.

Living-donor kidney transplant (LDKT) is the treatment of choice for patients with advanced kidney disease. Kidney paired donation (KPD), originally proposed to overcome immunological barriers, has now evolved to address biological and chronological incompatibilities and reduce financial disincentives. This strategy has allowed the maximization of the number of LDKTs. In 2021, of the 5,971 LDKTs performed, 1,115 (18.6%) were facilitated by KPD. Although KPD programs vary in size and structure, privately owned KPD programs dominate the landscape. Participation in KPD is far from universal: it is not offered in 40% of transplant centers. Across the United States, there are large areas devoid of transplant centers that offer KPD. As a result, some donor and recipient candidates are missing opportunities for a successful LDKT. Some private KPD programs provide financial and legal protections to living donors. Therefore, access to such donor protections is variable and not available to all donors. In this perspective, we review the evolution of KPD programs, explore ways to enhance participation, discuss the need for transparency about living donation options to donor and recipient candidates, and ultimately call for national action for regulatory oversight and to make living kidney donation financially neutral regardless of participation in KPD.